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progression of periodontitis have pathologically migrated, as a conse- quence of periodontal attachment and bone loss. In these patients with a healthy but reduced periodontium, the results of OT may be different, compared with patients without attachment loss, or the orthodontic tooth movements may cause adverse effects on the affected teeth or on the remaining periodontium.
OT in periodontitis patients was reported in a few studies irrespective of the type of orthodontic movement or anchorage system used. In the conventional anchorage group, one study (Melsen et al., 1989) reported 1 – 3 mm of root resorption when the incisors were orthodontically intruded, while in another study (Corrente et al., 2003) no resorption using similar orthodontic movements was reported. In the skeletal anchorage group, only one study reported apical root resorption (ranging from 0.2 to 0.4 mm) in the periodontally treated group, while similar root resorption was also reported in periodontally healthy patients treated by OT (ranging from 1 to 1.5 mm). Balance of benefit and harm OT has no detrimental effects on periodontal conditions in periodonti- tis patients with a healthy but reduced periodontium, provided the results of periodontal therapy are maintained during the active OT. Overall, the benefits exceed the potential harms.
Available evidence
Number and design of included studies The SR by Martin et al. (2021) included 35 studies. These studies were mainly case series with a pre – post design (15 prospective and 5 retro- spective) or cohort studies (4 prospective and 2 retrospective) evalu- ating the outcomes of OT in periodontitis patients; or studies comparing the outcomes of OT between periodontitis versus non- periodontitis patients, either with RCTs (1 split mouth and 7 with par- allel arms), or CCT (1 split mouth). Risk of bias The overall quality of the included studies was evaluated as “ low ” . From the eight RCTs assessed using RoB 2.0 tool, the overall bias assessment was rated as “ high ” for two RCTs; as “ low risk of bias ” for three RCTs and as “ some concern ” in the other three. Regarding the 20 pre – post intervention studies, only 1 was rated as “ good ” quality, 10 was rated as “ fair ” (moderate risk of bias) and 9 as “ poor ” . The cohort studies were rated with the Newcastle – Ottawa scale (NOS) scale with 4 being rated as “ fair ” quality, one as “ poor ” and one as “ good ” .
Consistency All studies reported the same tendency.
Overall certainty of the evidence The evidence was graded as moderate since a relevant number of stud- ies reported consistent results, albeit with moderate to high risk of bias.
From evidence to recommendation — additional considerations
Acceptability Considering the likely benefits (improved tooth position, functional occlusion, and aesthetics), this treatment is well accepted by the patients, although there is lack of evidence on patient-reported out- comes (PROMs) from the referred studies. Feasibility, ethical and economic considerations It should be considered that OT in patients with a reduced per- iodontium may be a complex treatment frequently requiring applica- tion of complicated devices and appliances, which requires that appropriate specialists or dentists with advanced training implement these treatments. Furthermore, these orthodontic treatments are usu- ally long (up to 2 years) and require regular visits, which imposes the patient or the health system with considerable costs. There are, how- ever, no available cost-effectiveness studies for these combined perio-ortho treatments. The considerable costs needed for these treatments are mainly financially self-supported by the affected indi- viduals in many European countries, what may result in inequity when no healthcare funding is available. Furthermore, the availability for appropriate professionals to render these complex treatments may vary widely.
Effect sizes and clinical relevance A. Periodontal outcomes (PPD and CAL)
In patients without periodontitis, changes in CAL (mm) (mean effect — ME = 0.248; 95% CI [ 0.055; 0.551]; p = .109) were mini- mal and non-statistically significant across time ( p > .05). For changes in PPD (mm), a statistically significant reduction was observed (ME = 0.325; 95% CI [0.123; 0.526]; p < .001). In patients with treated periodontitis, no significant changes were observed in CAL (mm) (ME = 0.202; 95% CI [ 0.018; 0.422]; p = .072). There was a slight reduction in PPD (mm) (ME = 0.129;
95% CI [0.058; 0.200]; p < .001), during OT. B. Gingival inflammation and gingival recession
In patients without periodontitis, changes in BOP (%) (ME = 3.63; 95% CI [ 2.11; 9.37]; p = .215) and in gingival recession (REC) (mm) (ns = 2, np = 26; ME = 0.23; 95% CI [ 0.32; 0.77]; p = .418) were minimal and non-statistically significant ( p > .05). In patients with treated periodontitis, also changes in BOP (%) (ME = 0.96; 95% CI [ 0.77; 2.69]; p = .278) or REC (mm) (ME = 0.08; 95% CI [ 0.37; 0.53]; p = .731) were minimal during OT and not statistically significant. C. Root resorption Due to the scarcity of the data, no meta-analyses could be con- structed for adverse effects. The advent of root resorption after
Legal considerations There are usually no legal constraints to OT.
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